Abigail English

Confidential health care for adolescents: Position paper of the Society for Adolescent Medicine

• Confidentiality protection is an essential component of health care for adolescents because it is consistent with their development of maturity and autonomy and without it, some adolescents will forgo care. • Confidential health care should be available, especially to encourage adolescents to seek health care for sensitive concerns and to ensure that they provide complete and candid information to their health care providers. • Health care professionals should educate adolescent patients and their families about the meaning and importance of confidentiality, the scope of confidentiality protection, and the limits to confidentiality. • Health care professionals should support effective communication between adolescents and their parents or other caretakers. Participation of parents in the health care of their adolescents should usually be encouraged, but should not be mandated. • Health care professionals and delivery systems should review and, if necessary, revise their procedures (including scheduling, billing, and recordkeeping) to ensure that adolescents’ privacy and the confidentiality of their health information are protected to the extent possible. • Health care professionals should receive education and ongoing training to ensure that they know and understand the state and federal consent and confidentiality laws relevant to the delivery of health services to adolescents and have the skills to apply these laws when delivering clinical care. • Laws that allow minors to give their own consent for all or some types of health care and that protect the confidentiality of adolescents’ health care information are fundamentally necessary to allow health care professionals to provide appropriate health care to adolescents and should be maintained. • Research related to confidentiality and adolescent health care should be placed within a broad research agenda focused on finding ways to increase the numbers of adolescents who receive high quality health care for the wide range of health issues important in this age group. Future research should investigate the impact of providing or limiting confidential adolescent health services on specific health outcomes, inform strategies to address system-level barriers to provision of confidential adolescent services, and define ways that health care professionals can encourage parentteen communication without losing the trust of adolescent patients.

Increasing adolescent vaccination: barriers and strategies in the context of policy, legal, and financial issues.

PURPOSE To increase understanding of the policy, legal, and financial issues influencing efforts to achieve high rates of adolescent vaccination. METHODS We conducted semistructured telephone interviews with 49 key informants in nine states, five jurisdictions, and at the national level. We elicited: (a) experiences with human papillomavirus (HPV) and meningococcal vaccine programs; (b) perspectives on policy, legal, and financing issues influencing adolescent vaccine program effectiveness; and (c) strategies to increase rates of adolescent vaccination. Common and informative themes were identified by content analyses. RESULTS Participants reported that barriers to adolescent vaccination included: public concerns (insufficient knowledge, negative attitudes, safety concerns, controversy); practitioner concerns (insufficient knowledge or ambivalence about recommendations); delivery issues (insufficient access to or use of healthcare, vaccines not at healthcare site or part of routine care); minor consent issues; cost/financing issues; and lack of coordination in timing of vaccine recommendations, supply, and financing. Many barriers and promising strategies for overcoming them vary depending on adolescent age. For example, concerns about providing vaccines to prevent sexually transmitted diseases are less frequent with respect to older adolescents; issues of consent vary widely between 11 and 25 years of age; and financial barriers/potential solutions vary by age. We develop a framework to address policy, legal, and financial issues influencing adolescent vaccination based on adolescent age. CONCLUSIONS A comprehensive description of factors influencing adolescent vaccination reveals variation based on age. A framework that incorporates this complexity may enhance strategies to increase rates of vaccine delivery to adolescent populations.

Treating Adolescents: Legal and Ethical Considerations

Treating adolescents in the health care system raises significant legal and ethical issues related to consent for treatment, confidentiality of communications and records, and payment for care. The law provides many opportunities for adolescents to consent to their own care and offers significant protections of confidentiality. Publicly funded programs provide access to free care for some adolescents, but financial considerations continue to limit access for many poor and low-income adolescents. In addition to legal concerns, serious ethical dilemmas arise, particularly with respect to treatment of special populations of adolescents. Resolution of the legal and ethical questions requires cooperation of professionals from many disciplines.

Legal basis of consent for health care and vaccination for adolescents.

State law is generally the controlling authority for whether parental consent is required or minors may consent for their own health care, including vaccination. At the federal level, no vaccination consent law exists; however, federal law requires that vaccine information statements be given to the parent or another person who is qualified under state law to consent to vaccination of a minor. All states allow minors to consent for their own health care in some circumstances on the basis of either (1) their status (eg, age, emancipation, marriage) or (2) the kind of health care services they are seeking (eg, family planning services, treatment of sexually transmitted disease). In each state, a specific analysis of laws will be required to determine the circumstances under which a minor can consent for vaccination.

Guidelines for Adolescent Health Research: Legal Perspectives

During the past decade a growing awareness of the health problems of adolescents has been accompanied by efforts to address the health needs of the adolescent population in appropriate ways. Research studies and clinical trials that include adolescents as research participants are being undertaken with increasing frequency and can contribute significantly to these efforts. Adolescents participation in health-related research studies can indirectly help to expand their access to services by providing important information that can be used in several significant ways: to facilitate policy and program development; to design appropriate prevention and treatment strategies for this age group; to monitor trends for evaluation; and to advocate for increased funding and services. Health research that involves adolescents as participants should be facilitated when the research will benefit adolescents either individually or as a group and when adolescent participants can be protected from undue risk. In some cases the legal requirements that govern the participation of adolescents in research operate in effect as a barrier to that participation since many institutional review boards (IRBs) reviewing research protocols are uncertain about how to apply legal requirements to the adolescent population. (excerpt)

HIV infection and AIDS in adolescents: a position paper of the society for adolescent medicine

This article focuses on HIV infection and AIDS in adolescents and its prevention. It briefly reviews the epidemiology of AIDS and HIV infection in adolescents; the clinical profile medical care and access to services of HIV-infected adolescents in high-risk situations; and HIV counseling and testing. Also presented are substantial recommendations on prevention that are strategic to epidemiology clinical profile and medical care HIV counseling and testing special populations and research.

Runaway and street youth at risk for HIV infection: Legal and ethical issues in access to care

Significant numbers of runaway and street youth are at risk for human immunodeficiency virus (HIV) infection. These youth are physically, socially, and psychologically vulnerable and need access to health care and related services. Legal and ethical concerns of consent and confidentiality may limit their access, although in many states the law allows some minors to consent to HIV testing and treatment and protects confidentiality of HIV-related information. Appropriate pretest and posttest counseling and follow-up for youth at risk of infection are essential. Limited access to HIV treatment for youth testing positive raises serious ethical concerns. Access to comprehensive treatment is currently limited by lack of adequate financing, despite a patchwork of numerous public funding sources providing some coverage for treatment of HIV and acquired immunodeficiency syndrome (AIDS). Research studies and clinical trials are critical elements in the planning and delivery of HIV-related services to adolescents, but require consideration of special ethical and legal concerns.

Health Care Reform and Adolescents—An Agenda for the Lifespan: A Position Paper of the Society for Adolescent Medicine

New opportunities now exist in the United States to achieve significant health care reform. The Society for Adolescent Medicine believes that health care reform must address the needs of everyone, whatever their age, race, national origin, income level, social circumstance, or health care needs. To achieve reforms that are meaningful for all, it is essential to address the specific needs of adolescents. Many aspects of health care reform that are needed for adults and for younger children will also help adolescents. However, adolescents require special attention and services to promote healthy development and a safe transition to adulthood. Adolescence provides a unique opportunity to prevent health conditions and behaviors with life-long implications for individual young people and for society. The second decade of life is a unique period, with significant growth and development on a scale matched only during infancy. Many adolescents experiment with ‘‘adult’’ behaviors and are increasingly independent in personal habits. These behaviors and habits—such as tobacco and alcohol use, other substance use and abuse, diet, exercise, sexual behavior, and driving—have significant implications for health. Indeed, the major causes of adult morbidity and mortality, such as heart and lung disease, diabetes, or cancer, are linked to these behaviors and habits, many of which have their onset during the second decade of life, and become ingrained in the early twenties. Health care services can play a key role in primary prevention of health problems and in enabling those with chronic conditions to manage their health effectively as they transition to adulthood. Ensuring adolescents’ access to high-quality, developmentally appropriate, affordable health care services lays the foundation for a lifetime of good health and health habits, and prepares adolescents to be productive, engaged citizens through their young adult years and beyond. This statement outlines principles to ensure that health care reform is meaningful for adolescents and also for young adults.

Innovations in preventive mental health care services for adolescents.

PURPOSE This descriptive study examined programs designed to provide mental health-related preventive services to at-risk adolescents. METHODS Qualitative interviews were conducted with state and local program directors and key personnel in public health and mental health departments and academic researchers who have initiated preventive services. RESULTS States and local communities offer varied mental health-related preventive services for high-risk adolescents in diverse settings. Services include public education, screening, early intervention for adolescents, and educational programs for primary care providers. Funding mechanisms include state general funds, foundation grants, and Medicaid and the State Childrens Health Insurance Program dollars. Evaluation is essential to maintain services and to persuade funders and other stakeholders to sustain these efforts. CONCLUSIONS State and local prevention-related mental health programs have been implemented with limited funding, but significant local advocacy and community support. More extensive evaluation and cost effectiveness studies may encourage policymakers to expand services. Further data are necessary to determine how prevention-related mental health programs can best serve vulnerable youth.

Clinical preventive services for adolescents: position paper of the Society for Adolescent Medicine.

Over the past several years, new vaccines have become available to prevent serious illnesses and conditions in the adolescent population. Several have already been approved by the FDA for use in this age group; others are still in development. Recently, significant public attention has been focused on the availability of vaccines for several strains of HPV, to prevent both cervical cancer and genital warts. Prior to that, the vaccine for Hepatitis B was approved and recommended for the adolescent age group. Others currently available and recommended include vaccines for pertussis, meningitis, and influenza. In the future, additional vaccines are expected to become available for sexually transmitted and communicable diseases such as herpes simplex virus and HIV. Unfortunately, financial limitations and consent requirements can impede adolescents’ access to the vaccines that are recommended for their age group. However, a variety of policy options exist for overcoming the barriers and expanding access. These policy options are grounded both in international principles of human rights and in the existing framework of laws in the United States, and can be enhanced by attending to variations in age and developmental status among adolescents.